Higashida R T, Lahue B J, Torbey M T, Hopkins L N, Leip E, Hanley D F
Department of Radiology, University of California, San Francisco Medical Center, San Francisco, CA 94143-0628, USA.
AJNR Am J Neuroradiol. 2007 Jan;28(1):146-51.
With advances in neuroimaging, unruptured cerebral aneurysms are being diagnosed more frequently. Until 1995, surgical clipping of the aneurysm was the only treatment available. Since then, a less invasive endovascular technique has been found effective in a trial of ruptured aneurysms. No efficacy studies comparing the 2 procedures for unruptured aneurysms exist to guide clinical decisions. The objective of this study was to assess effectiveness and outcomes of endovascular versus neurosurgical treatment for unruptured intracranial aneurysms.
This was a retrospective cohort study, using data collected over a 1-year time interval (between 1998 and 2000), from 429 hospitals, in 18 states, and representing 58% of the US population. A total of 2535 treated, unruptured cerebral aneurysm cases were evaluated. The measurements used were effectiveness as measured by hospital discharge outcomes: 1) mortality (in-hospital death), 2) adverse outcomes (death or discharge to a rehabilitation or nursing facility), 3) length of stay, and 4) hospital charges. Univariate analyses compared endovascular versus neurosurgical discharge outcomes. Multivariable models were adjusted for age, sex, region, Medicaid insurance status, year, hospital case volume, comorbidity score, and admission source.
Endovascular treatment was associated with fewer adverse outcomes (6.6% versus 13.2%), decreased mortality (0.9% versus 2.5%), shorter lengths of stay (4.5 versus 7.4 days), and lower hospital charges (42,044 dollars versus 47,567 dollars) compared with neurosurgical treatment (P < .05). After multivariable adjustment, neurosurgical cases had 70% greater odds of an adverse outcome, 30% increased hospital charges, and 80% longer length of stay compared with endovascular cases (P < .05).
The current analysis indicates that endovascular therapy is associated with significantly less morbidity, less mortality, and decreased hospital resource use at discharge, compared with conventional neurosurgical treatment for all unruptured aneurysms. Endovascular therapy, as a treatment alternative to surgical clipping, should be offered as a viable therapeutic option for all patients considering treatment of an unruptured cerebral aneurysm.
随着神经影像学的发展，未破裂脑动脉瘤的诊断越来越频繁。直到1995年，对动脉瘤进行手术夹闭是唯一可用的治疗方法。从那时起，一种侵入性较小的血管内技术在破裂动脉瘤的试验中被发现是有效的。目前尚无比较这两种治疗未破裂动脉瘤方法疗效的研究来指导临床决策。本研究的目的是评估血管内治疗与神经外科治疗未破裂颅内动脉瘤的有效性和治疗结果。
这是一项回顾性队列研究，使用在1年时间间隔（1998年至2000年）内从18个州的429家医院收集的数据，这些医院代表了美国58%的人口。共评估了2535例接受治疗的未破裂脑动脉瘤病例。所使用的测量指标是根据出院结果衡量的有效性：1）死亡率（住院死亡），2）不良结局（死亡或出院后入住康复机构或护理机构），3）住院时间，以及4）住院费用。单因素分析比较了血管内治疗与神经外科治疗的出院结果。多变量模型根据年龄、性别、地区、医疗补助保险状况、年份、医院病例数量、合并症评分和入院来源进行了调整。
与神经外科治疗相比，血管内治疗的不良结局较少（6.6%对13.2%），死亡率降低（0.9%对2.5%），住院时间缩短（4.5天对7.4天），住院费用降低（42,044美元对47,567美元）（P <.05）。经过多变量调整后，与血管内治疗病例相比，神经外科治疗病例出现不良结局的几率高70%，住院费用增加30%，住院时间长80%（P <.05）。
目前的分析表明，与所有未破裂动脉瘤的传统神经外科治疗相比，血管内治疗在出院时的发病率、死亡率显著降低，医院资源使用减少。血管内治疗作为手术夹闭的替代治疗方法，应作为所有考虑治疗未破裂脑动脉瘤患者的可行治疗选择。
